Morihisa Kitano

Aneurysm of coronary arteriovenous fistula presenting as a calcified mediastinal mass

A 61-year-old woman with a giant aneurysm of the coronary arterial fistula between the left anterior descending coronary artery and the main pulmonary artery underwent aneurysmal resection and closure of the fistula. This was a very unusual case with rare congenital malformation with secondary atherosclerotic change.

Omentoplasty in thoracic surgery

Plombage methods were designed for treating pulmonary tuberculosis surgically around 1945 when pulmonary tuberculosis was regarded as a “traitor disease” in Japan. Nagaishi had reported extrapleural synthetic resin ball plombage in 1948 as the world’s first case, but it was complicated by empyema due to perforation of cavities and rupture of lesions because the resin ball was hard. Later, fillers were improved by using soft material. At the present time, only air plombage and omentoplasty remain. Especially the latter has gained widespread use in the thoracic surgery field and become a standard procedure. Chronic empyema with bronchopleural fistula sometime requires surgical treatment despite the development of various antibiotics, but highly stressful surgery that can cause reduced pulmonary function or thoracic deformity must be avoided. Therefore, one-stage omentoplasty utilizing such omental multifunctions as hose action, angiogenesis, sucker action, and the immune reaction has been found to have clinical significance for thoracic empyema and its complications. This method is described in detail.

A case of anaplastic lymphoma kinase (ALK)-positive ciliated muconodular papillary tumor (CMPT) of the lung

Ciliated muconodular papillary tumor (CMPT) is a rare papillary tumor that arises in the peripheral lung fields and is associated with the proliferation of ciliate d and goblet cells and increased mucin production. We report a case of CMPT involving the rearrangement of the anaplastic lymphoma kinase (ALK) gene. The patient was an 84‐year‐old Japanese female who had exhibited a small nodular shadow on chest computed tomography during a regular checkup 10 years ago. She underwent a partial resection of segment S10 of the right lung. The cut surface of the surgical specimen revealed a well‐circumscribed, jelly‐like mass measuring 8 × 8 × 10 mm. Histologically, the tumor was composed of a mixture of ciliated, goblet, and basal cells arranged in a papillary pattern together with pools of mucin. A diagnosis of CMPT was made. The lung tumor cells were subjected to fluorescent in situ hybridization and highly sensitive immunohistochemical staining for the ALK protein, both of which produced positive results. CMPT usually follows a favorable course, but the exact nature of this tumor; i.e., whether it is benign or malignant, has not been established. This is the first reported case of an ALK‐positive CMPT.

Systemic artery-to-pulmonary artery shunt after using an omental pedicle flap

A 66-year-old man was hospitalized because of hemoptysis. Four years earlier, he had undergone an operation involving the use of an omental pedicle flap that was supplied by the right gastroepiploic artery for the treatment of empyema. Arteriography revealed that the right gastroepiploic artery communicated with the periphery of the right pulmonary artery. The right gastroepiploic artery was divided surgically.

Three cases in which preoperative evaluation of pulmonary vessels was useful using Versa Web

当院では，肺葉切除・区域切除症例を対象として，CT angiographyを作成し術前に肺動静脈の同定，variationの有無を確認してきた．2009年1月より320列CTが導入され，以前に比べて詳細な画像をえられるようになり血管走行の確認が容易になったが，CT angiographyの作成は決まった条件により作成されるため，症例によっては手術に必要な血管の描出が不良となり，その走行の確認が困難な場合があった．この問題を解決する目的でWeb browserを利用したVersa WebTM（ザイオソフト社製）を導入したところ（2009年9月），術者自身が簡単にCT angiographyを作成・保存できるようになった．術前に作成したCT angiographyを用いて肺血管の詳細なmappingを行うことで，肺切除術，とりわけ上葉切除や区域切除および不全分葉症例での手術をより安全に迅速に行うことが可能と考えられた．

A case of pryce type I intrapulmonary sequestration

A twenty-year-old asymptomatic man hospitalized because of a vascular murmur and abnormal shadow in the left lower lung on X-ray film. An aortogram revealed an abnormal artery arising from the descending thoracic aorta and supplying the left basal segment, which had no other pulmonary arteries. Although lung ventilation scintigraphy demonstrated reduced ventilation to the left lower lobe, bronchogram showed an almost normal bronchial tree except that peripheral branches were slightly thin. A clinical diagnosis of Pryce type I intrapulmonary sequestration was made, and left lower lobectomy was performed successfully. We have analyzed 31 cases of Pryce type I intrapulmonary sequestration in Japan. A vascular murmur is often heard, and a chest X-ray usually shows either a mass shadow or increased vascular markings. In most of those cases, an abnormal artery arises from the descending thoracic aorta and it supplies the left basal segment. Because this type of sequestration causes hemoptysis and infections, surgical intervention is indicated.

Effectiveness of Thoracic Egg in primary spontaneous pneumothorax-for safer outpatient treatment of pneumothorax-

携帯型気胸ドレナージキット（ソラシックエッグ®：以下TE）の有用性についてretrospectiveに検討した．対象は2007年3月から2008年9月にTEを使用して治療を行った自然気胸患者43例．患者の平均年齢は33歳（13～69歳），男性32例，女性11例，患側は右18例，左25例，初発27例，再発16例であった．17例は外来通院のみで治療が可能であった．空気漏れの持続や気胸の再発で手術を行った症例は18例であった．気胸の悪化により持続吸引やトロッカーカテーテルへの入れ換えが必要な症例は認められなかった．カテーテルの屈曲による閉塞のため1例でTEの再挿入が必要であった．挿入後の自己抜去例は2例であったが，肺の虚脱はなく再挿入は不要であった．TEのカテーテル部分と排液ボトルの間に三方活栓を留置することで抜去前にクランプによる肺瘻確認を容易に行うことが可能であった．TEは排液の多い気胸でも使用可能であり，自然気胸の外来治療に有用と考えられた．

The Utility of Arithmetically Combining Prognostic Factors in Patients Undergoing Resection of Pulmonary metastases.

転移性肺腫瘍手術例38例を対象として各因子別に2群に分類して術後成績の検討を行った. 全例の5年生存率は26.5%であった. 肺内転移数 (N), 腫瘍倍加時間 (TDT), 最大腫瘍径 (R), 原発巣切除から肺内転移巣出現までの非担癌期間, 原発巣の組織型, 術後化学療法の有無, 他臓器転移の有無により生存率を検討した. これら単独の因子別では生存率に統計学的有意差はみられなかった. これらの因子をさらに算術的に合成した指標についても検討を行った. TDT/Nが30を越える群, 30以下の群の5年生存率は各々, 49.4%, 0%であった (P=0.0045). TDT/Rが25を越える群, 25以下の群の4生率は31.8%, 16.7%であった (p=0.0150).単独で有意差のみられなかった因子も合成することにより新たに有意な指標となった. 特に増殖速度と肺野着床能の合成概念であるTDT/Nが30以上を示すことは良好な結果の得られる手術対象群であると考えられた.